Healthcare Provider Details

I. General information

NPI: 1164452249
Provider Name (Legal Business Name): RUSH SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 CHETCO AVENUE
BROOKINGS OR
97415
US

IV. Provider business mailing address

94220 FOURTH STREET
GOLD BEACH OR
97444
US

V. Phone/Fax

Practice location:
  • Phone: 541-813-1835
  • Fax: 541-813-1282
Mailing address:
  • Phone: 541-247-3000
  • Fax: 541-247-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number07-1579
License Number StateOR

VIII. Authorized Official

Name: VIRGINIA A. RAZO
Title or Position: C.E.O.
Credential: PHARM. D
Phone: 541-247-3108